Counseling High-risk Adults to Prevent CVD Shows Benefit, Says USPSTF

Draft Recommendation Covers Overweight, Obese People With Other Risk Factors

On May 12, the U.S. Preventive Services Task Force (USPSTF) issued a draft statement recommending behavioral counseling to promote a healthy diet and physical activity for cardiovascular disease (CVD) prevention in adults at high risk for the disease.

According to USPSTF Chair and family physician Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo., this latest draft recommendation bears some similarity to a recommendation the task force issued in 2012,(www.uspreventiveservicestaskforce.org) but that statement focused on behavioral counseling for CVD in adults without specific risk factors and stated that the evidence available at that time indicated the benefit of initiating such counseling in the primary care setting was small.

"For example, I'm seeing in clinic a 40-year-old nonsmoker, normal weight, who doesn't have high blood pressure and who has a good-looking cholesterol. Is it helpful for me to spend time counseling that person about healthy lifestyle?" LeFevre asked. "(The USPSTF’s) answer in 2012 was that there is some benefit, but it's not large, for primary care physicians to selectively counsel those folks based on their clinical judgment."

Who Is Covered by the Current Proposal?

The 2014 draft statement pertains only to people who are overweight and obese and who have at least one other known risk factor for heart disease, LeFevre said. These risk factors include high blood pressure, high cholesterol and impaired fasting glucose.

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The U.S. Preventive Services Task Force (USPSTF) has issued a draft statement recommending behavioral counseling to promote a healthy diet and physical activity for prevention of cardiovascular disease (CVD) in high-risk adults.

The draft recommendation pertains only to people who are overweight or obese and who have at least one other known risk factor or CVD.

USPSTF Chair and family physician Michael LeFevre, M.D., M.S.P.H., encouraged FPs who choose to implement the recommendation to use whatever resources they have at their disposal.

"Counseling these people seems to offer a benefit," he said. "We see a pretty consistent reduction of across-the-board risk factors -- cholesterol, glucose, weight and blood pressure -- and increases in physical activity. All of those changes are relativity modest in magnitude, but combined, we think there is enough going on there to actually reduce people's risk for heart disease."

In 2012, the USPSTF also recommended(www.uspreventiveservicestaskforce.org) screening all adults for obesity and offering intensive, multicomponent behavioral interventions to patients with a BMI of 30 kg/m2 or more to reduce their risk for CVD and other health problems. The current draft recommendation folds in the group of people who are considered overweight, with a BMI typically from 25 kg/m2 to 30 kg/m2, who also have one other risk factor for CVD, LeFevre said.

LeFevre said that as is typical with USPSTF recommendations, the group didn’t review evidence that directly indicated heart disease rates were going to go down as a result of behavioral counseling.

"But we do believe that we have evidence that the change in risk factors will be sufficient to lower the risk for heart disease," he said. "There is a chain of evidence that isn't direct in this case. But we did see modest changes in blood pressure, cholesterol, glucose and physical activity that, combined, should lower the risk for heart disease."

Application at Practice Level Will Vary

Recognizing that family physicians in practice today may not be equipped to provide or may not have ready access to the type of behavioral counseling the USPSTF is proposing, LeFevre encouraged family physicians who choose to implement the recommendation to use whatever resources they have at their disposal.

"Some family physicians might look to incorporate this recommendation into their practices and figure out how they are going to provide, as a service, this type of counseling either themselves or as a part of the medical team available to them," he said. "Others might ask their local hospitals if they would be interested in starting a similar program so that they could refer patients to it. Others might team up with a local gym, YMCA, or other organization that has access to health coaches or dietitians."

LeFevre said that typically, this type of behavioral counseling is conducted by dietitians or health coaches. Many such programs are executed as group counseling sessions, he added.

What's To Come?

Looking down the road, LeFevre said he thinks the USPSTF's recommendation regarding these types of behavioral counseling programs could lead to more of them being established across the country. Insurance companies might start to notice and support them, which would lead to additional programs.

"If the payers follow, and start to reimburse for this type of counseling, that makes it much more likely these types of programs will continue to develop," LeFevre said.

The draft recommendation statement is available for comment until June 9 at 5 p.m. EDT.